Surgery of Neonates: What's New in Dealing with Perioperative Complications?

Neonatal surgery is a recognized subspecialty of pediatric surgery, which has grown and flourished over the last six decades. As many say, neonatal surgery is the discipline that distinguishes us (pediatric surgeons) from our colleague adult surgeons.

Over the years, with the progress in neonatal critical care, we have observed an improvement in the survival of neonates with younger gestational age, lighter birth weight, and more challenging clinical conditions. As a result, we have been dealing with increasingly complex neonates that undergo increasingly complex operations, and may develop increasingly complex perioperative complications.

The surgical technology has progressed along. The introduction of new, more sophisticated, equipments has helped us develop advanced minimally invasive techniques to repair birth defects. However, the size and fragility of neonatal patients remain a challenge even for the most skilled surgeons, so that the new technologies have paradoxically increased the variety of perioperative complications.

The increased survival of complex babies and the progress in technologies (often uncritically diffused in the media) have caused an increase in parental expectations that treatment should always be effective and without complications. Unfortunately, we know this is not the case.

Although inherent part of surgical practice, complications are not thoroughly discussed in surgery textbooks. Complications have several consequences. First, the immediate and long-term burden on patients and their families, potentially also leading to malpractice litigations. Surgical neonates that have perioperative complications are at increased risk of death or irreversible problems, and may experience higher anxiety or stress in the long term.[1] Second, complications are associated with an increase in hospital stay and costs.[2] [3] Third, complications are frustrating and stressful events for the surgeon,[4] may cause anxiety, loss of confidence, and reduced job satisfaction.[5] Prevention and timely and correct management are key factors in dealing with complications. In his book “Complications: A Surgeon's Note on an Imperfect Science,” [6] Atul Gawande writes:

“The book's title, Complications, comes not just from the unexpected turns that can result in medicine but also, and more fundamentally, from my concern with the larger uncertainties and dilemmas that underlie what we do. This is the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I've joined the profession's ranks.”

Recognizing that complications of neonatal surgery also fall in this gray zone, in the present issue of the European Journal of Pediatric Surgery, pediatric surgeons from different countries update us on the perioperative complications following various neonatal surgical procedures.

Esophageal atresia is considered the epitome of pediatric surgery and is a highly rewarding disorder to treat. However, its perioperative complications can dreadfully impact the life of a child, touching also the long-term quality of life. Herein, Drs. Morini and colleagues describe the perioperative complications of esophageal atresia surgery and the possible strategies to prevent them.[7]

Congenital diaphragmatic hernia (CDH) is a birth defect where respiratory failure is the central issue. As a consequence, the management of ventilation plays a key role in reaching the stability required to allow surgical repair. In these neonates, perioperative complications can destabilize the delicate stability, thereby baffling all efforts made. Drs. Barroso and Correia-Pinto discuss the perioperative complications in patients with CDH, focusing also on the impact that the introduction of thoracoscopy has had on CDH.[8]

Necrotizing enterocolitis (NEC) is a devastating disease mainly affecting the preterm infants. Despite the efforts to prevent its development, the incidence of this condition remains the same, as well as the high morbidity and mortality rates. Drs. Mutanen and colleagues describe the perioperative complications that may arise from NEC surgery and its possible negative effects on the gastrointestinal and/or neurodevelopmental outcome of these fragile babies.[9]

Dr. Pakarinen has widely discussed the perioperative complications of surgery for Hirschsprung's disease.[10] These complications may put the patient functional outcome at severe risk and as discussed “they are best treated by efficient prevention.”

Drs. Wilde and colleagues describe the surgical techniques for the treatment of biliary atresia and choledochal malformations and review-specific perioperative complications of these surgical procedures.[11]

The thoracoscopic approach is gaining ground in lung surgery in the neonates. The purported advantages include less pain, better cosmesis (including thoracic asymmetry), and shorter length of hospital stay. However, every new technique must be compared with the traditional one not only for the good but also for the bad. Dr. Zoeller and colleagues analyze the perioperative complications of thoracoscopic approach for lung surgery procedures in neonates.[12]

Pyloromyotomy is a well-defined treatment for hypertrophic pyloric stenosis. However, perioperative complications such as mucosal perforation may still portend catastrophic consequences. Drs. Kelay and Hall deal with perioperative complications of pyloromyotomy from their risk factors to treatment options.[13]

We trust you will enjoy this review block section and find it useful in your everyday surgical activity. We hope it helps share our experience on complications and the teachings that can be derived from them.

• References

• 1 Noeker M, Schmitz M, Schmiedeke E. , et al. Medical predictors of psychological anxieties in VATER patients. Pediatr Surg Int 2011; 27 (10) 1079-1083
• 2 Landisch RM, Colwell RC, Densmore JC. Infant gastrostomy outcomes: the cost of complications. J Pediatr Surg 2016; 51 (12) 1976-1982
• 3 Uribe-Leitz M, McCracken CE, Heiss KF, Wulkan ML, Raval MV. The influence of infectious complications in gastroschisis on costs and length of stay. Am J Perinatol 2017; 34 (01) 62-69
• 4 Pinto A, Faiz O, Bicknell C, Vincent C. Acute traumatic stress among surgeons after major surgical complications. Am J Surg 2014; 208 (04) 642-647
• 5 Waterman AD, Garbutt J, Hazel E. , et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007; 33 (08) 467-476
• 6 Gawande A. Complications: A Surgeon's Notes on an Imperfect Science. New York: Henry Holt and Company; 2002
• 7 Morini F, Conforti A, Bagolan P. Perioperative complications of esophageal atresia. Eur J Pediatr Surg 2018; 28 (02) 133-140
• 8 Barroso C, Correia-Pinto J. Perioperative complications of congenital diaphragmatic hernia repair. Eur J Pediatr Surg 2018; 28 (02) 141-147
• 9 Mutanen A, Pierro A, Zani A. Perioperative complications following surgery for necrotizing enterocolitis. Eur J Pediatr Surg 2018; 28 (02) 148-151
• 10 Pakarinen M. Perioperative complications of transanal pull-through surgery for Hirschsprung's disease. Eur J Pediatr Surg 2018; 28 (02) 152-155
• 11 Wilde JCH, Calinescu AM, Wildhaber BE. Perioperative complications in neonatal surgery: biliary atresia and choledochal malformations. Eur J Pediatr Surg 2018; 28 (02) 156-162
• 12 Zoeller C, Ure BM, Dingemann J. Perioperative complications of video-assisted thoracoscopic pulmonary procedures in neonates and infants. Eur J Pediatr Surg 2018; 28 (02) 163-170
• 13 Kelay A, Hall NJ. Perioperative complications of surgery for hypertrophic pyloric stenosis. Eur J Pediatr Surg 2018; 28 (02) 171-175